riskstoearlychildhoodhealthanddevelopmentinthe...

Hindawi Publishing CorporationInternational Journal of PediatricsVolume 2012, Article ID 820290, 16 pagesdoi:10.1155/2012/820290

Research Article

Risks to Early Childhood Health and Development in thePostconflict Transition of Northern Uganda

Theresa A. McElroy,1 Stella Atim,2 Charles P. Larson,3 and Robert W. Armstrong4

1 Canadian Child Health Clinician Scientist Training Program, and University of British Columbia,Vancouver, BC, Canada V6T 1Z1

2 Child Health and Development Centre, Makerere University, Kampala, Uganda3 Centre for International Child Health, BC Childrens Hospital and University of British Columbia,Vancouver, BC, Canada V6T 1Z3

4 Medical College, East Africa, Aga Khan University Nairobi, Kenya

Correspondence should be addressed to Theresa A. McElroy, tree [email protected]

Received 15 September 2011; Revised 25 November 2011; Accepted 6 December 2011

Academic Editor: Michael Siegal

Copyright © 2012 Theresa A. McElroy et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Research from numerous fields of science has documented the critical importance of nurturing environments in shaping youngchildren’s future health and development. We studied the environments of early childhood (birth to 3 years) during postconflict,postdisplacement transition in northern Uganda. The aim was to better understand perceived needs and risks in order torecommend targeted policy and interventions. Methods. Applied ethnography (interview, focus group discussion, case study,observational methods, document review) in 3 sites over 1 year. Results. Transition was a prolonged and deeply challenging phasefor families. Young children were exposed to a myriad of risk factors. Participants recognized risks as potential barriers to positivelong-term life outcomes for children and society but circumstances generally rendered them unable to make substantive changes.Conclusions. Support structures were inadequate to protect the health and development of children during the transitional periodplacing infants and young children at risk. Specific policy and practice guidelines are required that focus on protecting hard-to-reach, vulnerable, children during what can be prolonged and extremely difficult periods of transition.

1. Introduction

Research from biology to the social sciences continues tobuild strong evidence demonstrating that the conditions inwhich young children live and grow are determinants of theirhealth and developmental trajectories [1–13]. The WorldHealth Organization’s Commission on Social Determinantsin Health [14, 15] commissioned a report on early childhooddevelopment, completed in 2007 [2, 3]. Its key messagesinclude the following: the early years are the most criticalperiod in human development; numerous physical health,mental health, and social outcomes are strongly influencedby conditions experienced in early childhood; failure toprovide nurturing environments not only impacts individuallife chances but can threaten sustainable, peaceful, equitabledevelopment in society; caregivers require support from

government and other agencies (local to international) tocreate nurturing environments for children [2]. Stimulationreceived in responsive and nurturing relationships, exposureto safe environments, and meeting of physical needs like ade-quate nutrition [1] provide what children need for healthydevelopment.

All too often young children are exposed to conditionsthat do not meet their most basic needs for health anddevelopment. The literature conservatively estimates thatworldwide more than 200 million children under the age of5 years living in low income countries (such as Uganda) failto reach their developmental potential [6]. In such contextsresearch has demonstrated that children are faced withnumerous factors associated with significant risk to devel-opment including poverty, malnutrition, poor health (pre-ventable and treatable infectious diseases), and psychosocial

2 International Journal of Pediatrics

factors (exposure to violence, maternal depression, lack ofstimulation/social interaction in the home environment)[12]. Those living in the least nurturing environments andwith the greatest levels of risk manifest the poorest outcomes.One such situation is that of prolonged war and internaldisplacement.

War and displacement create conditions of high riskor vulnerability for children’s development and well-beingthrough increased exposure to conditions such as economicdevastation, destruction of basic infrastructure (i.e., healthcare, education, legal protection), reductions in hygiene andsanitation with resultant elevations in disease spread, andbreakdown of social support structures that are thwartedfrom nurturing and protecting children [16–19]. Theseconditions of ubiquitous collapse of nurturing environmentsdo not end with the cessation of conflict but have enduringimpact on children, families, communities, and societies;impact that requires time and prolonged effort to rebuildand restore [17, 19]. Additionally, factors such as lost infras-tructure and mass population movement can make childrendifficult to reach and hence difficult to serve with appropriateinterventions to mitigate risks. Nonetheless, the postconflicttransition can be of long duration and the negative impactmay be the most challenging to children in the first threeyears of life when critical and sensitive periods of braindevelopment can be compromised. Accordingly, this studysought to document the environments of early childhood(birth to 3 years) in a postconflict, postdisplacement settingin northern Uganda in order to better understand the needsand risks to health and development and to examine ways oftargeting policies and practices that can serve to mitigate riskin these difficult circumstances.

2. Methods

2.1. Background. The Region of Northern Uganda. The 20-year war waged in northern Uganda (1986–2006) pre-dominantly between the LRA rebel insurgents and thegovernment forces was politically complex, enduring, andvicious. Numerous authors have written detailed accounts ofits history, politics, and nuances [20–24]. From the earliestdays of the war, civilians were subject to looting and/ordestruction of their familial resources such as cattle and live-stock, devastation of health and educational infrastructure,and personal violence—rapes, beatings, killings, and massabductions to populate the rebel forces. This included anestimated 66,000 youth ages 14 to 30 [25].

In 1996, the Ugandan government formally established“protected villages” (internal displacement camps) in urbanor central gathering areas throughout the north. Manypeople fled to such camps, but many more were forciblydisplaced into them. Despite the promised protection fromviolence and destruction that the camps were meant toprovide, atrocities continued against the civilian populationperpetrated by a range of actors [21, 24, 26, 27]. In addi-tion, camps were frequently reported to: lack services andinfrastructure which contributed to food insecurity and poorhealth, have serious overcrowding and unhygienic conditions

leading to disease spread, and create conditions of severepoverty and inability to maintain independent livelihood[21, 24, 26, 28–30]. A health and mortality survey conductedin these camps in 2005 suggested that under 5 mortality(U5MR) rates were well above the emergency thresholds(i.e., 2.31 deaths per 10,000 children at risk per day),with the leading causes of child death being malaria/feverand a disease constellation that included diarrhoea, thrush,and malnutrition [29]. Relief agency involvement increaseddramatically from the time camps were established [31 in 21]to meet the emergency needs of a rapidly growing displacedpopulation, which reached approximately 2 million or 90%of the regional population by the end of 2005 [29].

The conflict in northern Uganda ended in 2006 with thesigning and renewal of a cessation of hostilities agreement[21]. The process of repatriation and reconstruction, whichwas still continuing in 2009-2010 when this research wasconducted, was complex, arduous, and protracted.

2.2. Population and Site Selection. The source population wasAcholi people (the dominant ethnic group in the region)living in the Amuru district of northern Uganda. This districtwas chosen as it was a relatively newly created district (2005)and according to key informants was underresourced andunderserved compared to neighbouring districts. It was alsoreported to be a region greatly impacted by war. In 2005 thedistrict held the highest number of displacement camps inthe Acholi region with 34 camps housing a population ofapproximately 257,000 [31]. At the start of the study in May2009, a reported 37% of people still remained living in thecamps in Amuru [32], and, by the end in June 2010, many ofthe camps had been officially closed with UNHCR reportingonly 14% of the internally displaced population remained incamps and settlements [31]. The study captured the periodof movement for 23% of the population in this district.

The target population in this study was children birthto three years old, from rural Agrarian families (the prewarlivelihood and lifestyle of the majority of the populationin the region) who experienced conditions of conflict anddisplacement. As this age group was highly dependent andunable to speak on their own behalf, the team used a mixof direct observation of children in their natural contextsand proxy respondents-family caregivers and communitymembers directly connected to young children.

The study population came from villages and internaldisplacement camps within three subcounties geographicallyspaced throughout the Amuru District: Pabo, Amuru, andAnaka. The villages and camps were selected purposivelyfrom the source population with the guidance of keyinformants to reflect a range of remoteness/accessibility,resource availability, and stage of resettlement/repatriation ofthe population (summarized in Table 1).

2.3. Participant Selection. The sampling was purposive orcriterion based. Participants were chosen due to theirpossession of the characteristics that allowed for in-depthexploration of the topic of study [33]. There were twokey inclusion criteria for these focus group and interview

International Journal of Pediatrics 3

Table 1: Description of research sites.

Pabo subcounty

Pabo camp had been one of the largest and most overcrowded camps during the war. Numerous emergencyrelief organizations had built up infrastructure in the area. As such, it was a relatively well-resourced andaccessible site located on a main road with two health centres, schools from nursery to secondary, markets,and other resources. The majority of participants from this site were residents of the Pabo camp and/or werein early phases of resettlement planning their return or moving back and forth between camp and villages.Half of the caregiver participants became case studies and those who resettled were followed back to theirvillages of resettlement in the subcounty.

Amuru subcounty

Site was very remote, difficult to access, and underresourced. The team travelled by car, motorbike, andhiking on foot. All but one of the water points in the camp were broken, the nearest health centre wasapproximately 11 km away and it was only open during weekday daytime hours, the road was badly ruttedwith potholes filled with mud and water, and the primary school was a mud and grass-thatched structurebuilt and supported by the community. Participants were either from the Omee II decongestion/transitioncamp (small camp established later in the war to move people closer to their land for subsistence and todecongest larger camps) or the surrounding villages. The majority of participants were either actively in theprocess of resettlement (moving back and forth to camp) or had recently resettled.

Anaka subcounty

Accessibility and resources/services were variable; that is, villages closer to the main centres tended to haveaccess to health care, education, and water points whereas those farther away from the centres were more likethe Omee II with very limited or inaccessible resources. The third site consisted of 8 parishes (villages andcamps) in the Anaka subcounty in order to capture people who had been resettled for varying durations andreach saturation on emerging themes.

participants: (1) experience of conflict and displacementand (2) knowledge or experience of young children asdirect caregivers, community leaders working for childrenand/or people with decision-making power and/or influencein regards to the well-being of young children in thenorthern Ugandan context. Within these broad criteria, aheterogeneous sample (also known as maximum variationsampling) was sought to capture the breadth of experiencesand maximize the potential for identification of all factorsassociated with the topic of study [33]. A total of 162 peoplewere either interviewed or participated in one of 26 focusgroup discussions (FGD): 35 primary female caregivers, 25fathers, 22 elders, 29 sibling caregivers, and 51 leaders, bothformal (teachers, health workers, government officials, NGOworkers, village health teams, child protection committeemembers) and traditional (traditional chiefs, traditionalbirth attendants). There were numerous other leaders andcommunity members who were engaged informally indialogues during research introductions or during otheractivities where participant observation was conducted suchas when the team was referring children to services. Table 2provides an overview showing the diversity of participants.Furthermore, in all sites people with disability were included,either a caregiver or the young child who was the focus ofobservation, making up approximately 10% of the familiesin this study. Impairments experienced by these individualsincluded quadriplegia, amputation (from landmine), visualimpairment, impaired mobility (i.e., high muscle tone fromneurological insult-cerebral malaria), hearing impairment(from chronic untreated ear infections).

Local leaders assisted with identifying participants withintheir communities according to the identified criteria. Onoccasion, participants referred other participants, and/or theteam directly approached caregivers who had young children.This variation in recruitment helped to guard against biases

that could have arisen from having participants identifiedsolely through leadership [34].

2.4. Conduct of Study. The research project had an interdis-ciplinary advisory committee composed of both Ugandanand Canadian professionals from the fields of paediatrics,preventative medicine and public health, anthropology,population health, and occupational therapy. The corefieldwork team consisted of an experienced ethnic Acholiresearcher, offering the emic perspective (cultural insider)and a Canadian researcher with a background in paediatricoccupational therapy, international health and qualitativeresearch offering the etic perspective (cultural outsider).Two Acholi research assistants, one male and one femaleassisted with data collection on occasion and worked ontranscriptions/translations and team discussions of emergentthemes. Training and preparation of the core fieldwork teamoccurred over a one-month period. The diversity of theresearch team provided both investigator and theoreticaltriangulation. Triangulation is a concept applied in quali-tative research whereby the topic of interest is approachedfrom a number of different angles (researchers, theoreticalbasis, methods, sites) to offset weaknesses, challenge biases,confirm the validity of findings, and, deepen understandingof concepts [35].

2.5. Data Collection Methods. Data collection occurred overa 1-year period, June 2009 to June 2010. Both the Acholiand the Canadian researcher jointly conducted the majorityof interviews, FGD, and observations. Dialogue occurred inthe local language of Lwo for all except two leader interviewsand was digitally audio recorded and then transcribed andtranslated into English. During development of the questionguides, a rigorous translation process was applied to ensureconcepts and meanings remained consistent from English toLwo [36].


Table 2: Demographics of participants.

LeadersPrimary femalecaregivers

Fathers Elders Sibling caregivers

Age range 20 to 68 years

16 to 72 years(includedgrandmothers caringfor orphans)

22 to 64 years 42 to 92 years 4 to 15 years

Sex28 male23 female

— —8 male14 female

6 male23 female

Highest level ofeducation achieved

No formal educationto graduate leveltraining

18 no formaleducation17 primary

23 primary1 senior1 postsecondarydiploma

15 none5 primary2 senior

5 none (some tooyoung)24 primary (some notcurrently in schooldue to poverty)

Livelihood

Leadership positionsdescribed aboveand/or farming(particularly for LCsand traditionalleaders)

Farming either inown land or forothers for food ormoney and/orsmall-scale trade/business

Farmers

Farming, smallbusiness, receivingaid, or supported byfamily

n/a

Marital status n/a

23 married or livingtogether12 separated orwidowed

All married or livingtogether(1 to 4 wives)

10 married11 widowed1 separated

n/a

Number of childrenrange

n/a1 to 8 children(9 were caring fororphans)

3 to 14 (includingbiological andorphans)

4 to 11 includingbiological andorphans

Most caring for 1 to 2charges

Current residence n/a

14 in camp3 living both in campand in village16 in village

10 in camp5 in both camp andvillage10 in village

8 in camp14 village

14 in camp15 village (most wereborn in camps orcame in early infancy)

This study applied multiple data collection methods tostrengthen the depth, authenticity, and credibility of thestudy through triangulation of data sources [35, 37]. Underthe methodological approach of applied ethnography, sevendata gathering methods were used.

2.5.1. Semistructured Interviews and Focus Group Discussions.Interviews conducted with individuals lasted approximatelyone hour. Focus group discussions (averaging 4–6 people)lasted approximately 2 hours (ranged from 35 minutes withsibling caregivers to 5 hours over 2 sessions with elderwomen). The open-ended semistructured interviews andFGDs were formulated to explore the context of children’slives and elicit perceptions about barriers and facilitatorsto young children’s health and development; questions andprobes evolved over the duration of the study to fullyexplore new ideas as they emerged. Participants were askeda range of questions to bring forth their knowledge, atti-tudes, beliefs, practices, and perceptions about life circum-stances/environments of young children (sample of guidingquestions in Table 3). Interviews and FGD were conducted ina range of locations such as homes (inside or outdoors undera tree), community buildings such as churches, or placesof work (for leaders); participants decided on the locationand whether they wanted to complete the interview/FGDin one session or multiple sessions. Privacy was ensured

in all settings. Following interviews with primary femalecaregivers, weight and height data was collected for theyoungest child under 3 years as an objective source of data tocorroborate caregiver’s perceptions about nutritional status.

2.5.2. Case Studies. This method involved visiting 6 childrenand their families every 4 to 6 weeks for a duration of 6months to 1 year as they transitioned following conflict.

2.5.3. Participant Observation in Camps, Villages, and inService Settings. The two primary field researchers (Cana-dian and Acholi) observed young children (with parentalpermission) and recorded what they were doing, how theywere doing it, with whom, and where in their daily lives andnatural settings. The observations were primarily recordedby the Canadian researcher in field journals and wereconfirmed with the Acholi researcher. Additionally, livingand working in the research sites afforded numerous oppor-tunities for recording observations of informal interactionsthat shed light on the context of young children’s lives,a technique called participant observation. For instance,on several occasions the research team brought childrenand caregivers to services such as hospital and recordedprominent features of these experiences. As Good andThorogood (2009) explain, “Observational methods allowthe researcher to record the mundane and unremarkable (to


Table 3: Examples of questions guiding interviews and focus groups.

Postwar living arrangements

(i) If still in the camp, explain why?:

Tell me about the impact of remaining in the camp for your children:

(ii) If in the village, tell me about your return to the village:

Tell me about the impact of returning to the village for your children:

Current service environment

(i) Describe the services that are currently available for young children:

(ii) Who are the existing or potential leaders who are (or could) address the needs of young children in your community?

Nutrition

(i) Describe what you should feed [NAME]:

(ii) Is there anything that makes it difficult or stops you from feeding [NAME] these foods? (probe: environment factors,social factors, number of times issue is experienced)

(iii) Is there anything that helps you feed [NAME] these foods?

(iv) Describe what happens when you cannot feed her/him the foods you describe:

Health

(i) Describe what [NAME] needs to be healthy:

(ii) Describe a safe and happy environment for a young child:

(iii) In the last two weeks has [NAME] been ill? (Probe illness and treatment.)

Caretaking practices

(i) Who spends the most time with young children? (Probe who takes care when caregiver is away or busy.)

(ii) How are young children supervised?

Developmental stimulation

(i) Describe what children learn in the (1st, 2nd, 3rd year of life-ask according to age):

(ii) How do they learn each of the skills you mentioned?

(iii) What does play look like for a child this age? (Probes: whom do they play with? Show me what he/she plays with.)

Questions about young children in war and displacement

(i) Describe what was different about raising young children before war when people lived in their villages:

(ii) Did this change during war? (describe)

Risks/barriers and enhancers/facilitators

(i) What is bad for young children? (i.e., what could prevent them from being as successful as possible?)

(ii) What should be done to make sure [NAME] and all young children have the chance to become successful adults?

Future outcomes:

(i) What do you want for [NAME]’s future? (Probes: valued outcomes, measures of success, desirable character traits.)

participants) features of everyday life that interviewees mightnot feel were worth commenting on and the context withinwhich they occur” (p. 148).

2.5.4. Document Analysis. This method involved reviewinggovernmental and nongovernmental reports, meeting min-utes, and news stories for information relevant to child-focused services provided or lacking.

The two field researchers held debriefing meetings eachday on the journey home from the research site whereobservations, emerging themes, clarifications, meanings, andareas for further exploration were discussed. Field notes on

impressions, observations, challenges, and reflections weretaken by both researchers and were kept together in fielddiaries.

2.6. Ethics. Ethical approval was obtained through the Mak-erere University (Uganda), The Uganda National Councilof Science and Technology, and the University of BritishColumbia (Canada). Additionally, permissions were soughtfrom senior leadership at the district and subcounty levelsand from local leadership in camps and villages, that is, thelocal council members in the region and/or the Rwot Kweri(traditional leaders). Informed consent was received from all


participants. Consent forms were read aloud to participantsin the local language to ensure that literacy and languagewere not barriers to providing consent. Confidentialitywas maintained by removing identifiers from responses inreports and publications, and participants chose the locationfor their interview or FGD.

2.7. Analysis. Content analysis was used to identify themesto describe the environment and the local perceptions ofits influence on early childhood health and development.Data analysis was an iterative, on-going process from thebeginning of data collection. Accordingly, the data collectionguides used for probing were revised numerous times overthe course of the year as analysis revealed new themesrequiring further exploration as well as themes that hadreached saturation. During fieldwork, a team approach wasemployed in the analytical process to ensure thoroughnessthrough alternative interpretations [38] and involved bothmembers of the fieldwork team and the advisory committee.

At the end of data collection, all transcripts wereimported into qualitative analysis software to assist withorganizing and sorting the data (field notes were analysedmanually as these were handwritten). The transcripts aloneconsisted of over 1700 single-spaced typed pages andtherefore required organization into manageable units. Theinitial organizational framework applied to the raw datawas to delineate it by research objectives. Using the analysissoftware, sections of the transcripts were highlighted andthen assigned a label or code, for instance, all data related topostconflict transition were coded “transition.” Once all ofthe transcripts were coded, the software program generateda report of raw data for each objective. The data set generatedfor early childhood in postconflict transition was the sourceof this paper.

Once there was a dataset generated for each objective,thematic analysis was applied. This involved noting that“certain phrases, events, activities, behaviours, ideas orother phenomena occur repeatedly in the data” [39, p. 46]and devising a code (or label) for these segments of thedata according to their message or what they were about.For instance “socioeconomic environment” was used tocode statements about poverty, household resources, cropfailures, food aid, and so forth. Once again, the softwaregenerated reports of raw data excerpts delineated by thesebroad themes. The ideas under each theme were thensummarized. The team compared and contrasted betweenand within participant’s reports, categories and typologieswere generated, and dialogue ensued about meaning of thedata [35]. Attention was given to both information thatrepeated regularly and information that was unusual orpresented alternate perspectives. Furthermore, patterns andrelationships in the data were also sought. For instance, thedata on “socioeconomic environment” was examined acrossparticipants in different phases of postconflict transition,from those still living in camps to those who had been settledin villages for varying lengths of time. Doing this allowed forexploration of associations between resettlement, resources,and reports of children’s status. This process was completed

in consultation with the advisory committee and reviewedby the fieldwork team to ensure agreement on results of theanalysis.

3. Findings

An estimated 90% of the northern population lived indisplacement by the end of war, and consequently, themajority of children in the region were born and raisedin camps. While issues of innumeracy made it difficult toquantify the exact number of years participants spent indisplacement, most reported living in camps for more than adecade. After such a prolonged period of restricted living, themove back to rural agrarian villages was a major transitionthat took time and impacted all facets of life; still, it waswelcomed. All participants indicated a desire to get childrenout of camps and away from the numerous threats to theirhealth, safety and well-being. These included overcrowdedconditions where disease spread readily, the undernutritionarising from lost livelihood, and the uncontrolled exposureto negative social influences such as violence and alcoholism.

This research purposefully sampled families in variousphases of postconflict transition in order to capture andunderstand the experiences and environments of youngchildren across resettlement. The findings have been groupedinto four sections which will outline broad themes cor-responding to children’s environments during transition:(1) the physical environment, (2) the socioeconomic envi-ronment, (3) the social (care-giving) environment, (4) theregional resource and service environments.

3.1. The Physical Environment and Process of Transition. Thissection highlights themes relating to the physical process oftransition that occurred following conflict end when familiesbegan to move back to rural villages. The major subthemes inthis data were (1) the caregivers’ focus on physical rebuildingof home and livelihood and (2) vulnerable families withoutland and social support.

3.1.1. Focus on Rebuilding. After prolonged displacement,the move back to former homesteads was reported tobe deeply challenging for caregivers. Rural village homestraditionally constructed of baked bricks and grass thatchroofs had long since disintegrated and had to be rebuiltfrom nothing along with structures like bathing shelters,latrines, and wells. For many, the agricultural lands hadgone fallow, which meant significant periods of time, andheavy and prolonged labour was required to clear, plant, andreestablish crops needed to feed the family. Furthermore,belongings, while usually minimal, had to be transportedgradually from the camps, usually carried on people’s headsor, less frequently, with a bicycle or hired motorbike. Thesegruelling activities of resettlement had to be prioritized inorder to re-build homes and livelihoods. However, whilecaregivers worked, young children could not live in remoteand wild regions without shelter, food, and services suchas health care. Consequently, both caregivers and leadersreported that children were being left in camps while adult


family members moved back and forth to the village tocomplete the necessary work (discussed further in social-cultural environment section).

I am living in the camp but not fully. I haveone leg here and one leg in the village. . .. Wehave homes (villages) which are very far, someof our homes are more than 10 miles away fromhere and you cannot gather your things all at thesame time to return to the village. I am pickingmy things one by one and if I was to go at once,life may not be easy for me there because I havejust cleared my gardens (agricultural land). Mychildren may lack food to eat when I take themthere so I have been leaving my children behind.My wife, and I we have been going back hometo build our huts and to clear gardens and toget a proper water source for drinking. With thehouse also I have just made the bricks, I do notonly need one hut, I need many huts becauseI have children. I have only planted potatoesthere. When I have planted enough crops, andthey are ready for harvest, that is when I willbe fully in my village, but right now I am notyet ready. Some of the crops I planted weredestroyed by sunshine. Father in FGD held in acamp.

3.1.2. Without Land and Support. While most familiesencountered in camps were in the process of rebuilding andresettling, in each camp studied, there were families whowere unable to return to their homes and agricultural landsdespite their desire to do so. In Acholi culture, marriedwomen moved to their husband’s land and males possessedmany of the skills essential to building homesteads such asconstructing structures and clearing fields. Consequently,female or child headed households, elders, people withdisabilities or weaknesses, and other categories of caregiverswho had limited social support (because male relatives haddied, abandoned, were abducted, or lived distantly), oftenspoke of being without return options. This included beingwithout access to land that would traditionally have housedand fed their families and/or having no one to help themrebuild. Left in the limbo of camps that were emptying andclosing, they spoke of great strain in trying to meet theirchildren’s most basic needs.

. . . It must be the one (the person) who hasnobody to help them build a hut who hasremained in the camp. The owners of these lands(camps) also want their land to be vacated butnow you will find that people have nowhere togo and you are quite confused. . .. 29-year-oldseparated mother of 4, still living in displacementcamp.

Well, for me, this war has brought me loss.My husband died, the father of my children.I have remained with children, with no one

to help them. Even I do not have any meansof taking care of them, it has become verydifficult; sorrow almost killed me. I would keepon remaining silent and I became sick. Mychest would pain me. There is no one whohelps me with the children. Even trying to get ameans of living is extremely difficult. ∼40-year-old widowed mother of 5, still living in a camp.

Furthermore, in each camp families were encounteredwho attempted to begin the process of resettlement only tobe stopped by land disputes with kin. Such disputes drovethem away from land they felt they had claim to and leftthem with limited means of providing for young childrenin their care. These disputes also caused rifts between kinwho in the past would have been a source of social supportfor children providing assistance such as childcare, advice,and/or material resources.

. . . The conflicts over land are so intense. Peopleare coming back alright, but they have becomeenemies. People are coming back but there aretoo many; they ran away from the war, they wentand multiplied so much, they came back withtheir young children. . . . It is because of land thatpeople have become enemies. It is as if they areno longer relatives. . .. One family; they disputedover land; they beat each other; they fought withhoes when they were digging in the garden; evenwith spears. . .. 20-year-old mother, living withher husband and 4 children (2 biological, 2 of kin)in their return to village.

3.2. The Socioeconomic Environment of Children after Conflict.This section illustrates themes relating to the socioeconomicenvironment of young children during postconflict transi-tion. The major subthemes are (1) the cessation of wartimesubsistence, (2) the origins and experience of poverty afterwar, (3) young children’s unmet needs, (4) hard work,poverty reduction approaches, and persistence for a betterfuture.

3.2.1. The Cessation of Wartime Subsistence. In camps, pro-visions provided by governmental, nongovernmental, andinternational organizations had attempted to meet children’sbasic needs (reports suggested major gaps, but it is beyondthe scope of this paper). However, when war ended andthere was a call to return home, a substantial portionof war-time subsistence ceased. Many of the provisionsthat had been supplied to some extent in camps such asfood, basic household necessities, and clean water werestopped or reduced to particular populations. This increasedvulnerability of children whose families had not yet madea transition from economic and nutritional dependenceto independence. When aid stopped, independence hadbe gained rapidly and almost exclusively through pursuitof productive occupations (primarily agricultural pursuits).Yet as the previous section described, the resumption oflivelihoods was not quick or easy.


It is hard to get food for my family because itis hardly there. Because I do not have a garden(agricultural lands), it is hard to get it. I haveto do piecemeal work or hired labour in otherpeoples’ garden if I have to eat, if I do notdo paid labour, we have to go hungry—withnothing to eat. . .. The most difficult is this year;it is too much for me. At least last year, peoplewere in the camps we were doing hired labour.We were getting food to eat from them (aidagencies), but now, they are no longer there atall. For us who have remained (in camps), thereis no food to eat; this is the worst year of all.—Single mother (one time widowed, one timeseparated) caring for 11 children while remainingliving in a camp with her elderly mother.

3.2.2. The Origins and Experience of Poverty after War.Poverty was noted to be oppressive to families and tobring suffering and misery to children. Participants talkedof having lost most if not all of their personal wealth andresources (i.e., livestock, crops, structures) during war anddisplacement to looting, destruction, and disintegration overtime. This position of abject poverty was people’s startingpoint in rebuilding their lives and caring for their children.

All of our cattle and the oxen for ploughing wereall raided during the war. We had to run bare-handed into the camps with our hands hangingloose by our sides, empty. And when comingback (to resettle in villages) we came back withour hands hanging loose with nothing andalthough we came back empty handed, withoutanything, we are struggling at least so that wecan carefully nurture our young children tomove on ahead; to ensure that they live a betterlife in the future. —45-year-old traditional birthattendant, widowed and caring for 5 children.

With human beings, if they are given birth to atleast there should be some training and caringand providing what is necessary for them . . ..There is no proper food; you are just tryingto revive your home. Other varieties of thingsneeded for the compound like cattle, they arenot there. Goats are not there . . . all of thesethings have defeated the Acholi, they are notthere, they are only trying to restore themand this thing is very hard. You have to dig(cultivate), you sometimes eat and at times youdo not. Somebody else may come and take yourown things from the garden (steal) and thisupsets us so much. My words end there. —34-year-old father of 6, with 2 spouses returning tothe village after 19 years of displacement.

Because agriculture was the primary productive skill baseof the majority of people, they were highly vulnerable toweather disturbances and pests that impeded crop growth.

In all three sites visited during the study year, droughts andrains caused crops to fail and all participants talked of aperiod of great and devastating hunger; several referred tothis experience as another war. In the past granaries wouldbe filled with food, livestock could be sold, or relatives withplenty could share, but current poverty meant they did nothave the resources to see them through such times and theirchildren suffered.

We are in the period of hunger, there is greathunger. The crops planted, sunshine has spoiltit. No food has yet been harvested. That is whywe still do not have enough. Life is difficult,the children are not getting enough. . .. Herechildren are sent to the hospital, they come backwhen their health has improved, but when theyhave been home for a few weeks, because ofthe bad food they are again taken back to thehospital. . . — Participant in FGD of elder womanconducted during drought.

. . . You may be interested and willing to seeyour child grow well but poverty will oppressyou. Right now, most people cannot afford toeat a meal in a day, they would wish to seetheir children grow well, but they lack anythingto give their children because there is no food.People’s food has dried up in their gardensbecause of the sunshine (drought). —ChildProtection Committee Member FGD.

Other factors reported to contribute to poverty subse-quent to conflict were caregiver disability or injury sustainedduring war that impeded the ability to do physical work andprovide for children, high fertility rates and large numbersof orphaned children that had to be cared for by extendedfamily, and not having social support and/or land. Themore of these factors being experienced, the more difficultit became to generate sufficient income to meet children’sneeds.

3.2.3. Children’s Basic Needs Go Unmet. In the environmentof poverty, reports of children’s unmet needs were pervasiveacross all categories of participants during transition. Thesituation was glaringly visible to the research team, whosaw far too many children in camps listless and wasted.The young children who were the subjects of caregiverinterviews/observation were weighed as an indicator ofnutritional status. Of the 12 children weighed during thedrought (May–August), only one 2-month-old, breastfedinfant was average weight. Nine of the children were severelymalnourished; at or below the first percentile for weight-for-age according to the World Health organization standards.Caregivers made an effort to protect their youngest membersduring the hunger, with all participants reporting that whenfood was scarce, young children were prioritized. Yet despitetheir efforts, often during this period food was simply notavailable.

. . . It really gives me heartache. I went to the hos-pital recently and many children were brought


from Pabo; many were blood transfused, manywere brought in with swollen bodies, I sawmany being blood transfused . . . . . . women aretrying to take care of children but are failingbecause their strength and ability is almost gone.They cannot get enough to feed the childrenand if children are all the time malnourished,they will not grow well and if they do notgrow well, in the future there is nothing muchthat will come out of them. . . We all here haveknowledge about feeding children, but what canknowledge do without food? NRC (NorwegianRefugee Council) taught us how to feed childrenand even many other NGOs taught us aboutnutrition and right now there are people whocome from UWMFO (Uganda Women andMen’s Financial Organization) and they are alsoteaching us about nutrition, they teach us aboutagriculture and how we can make children growup healthy, they have a lot of knowledge theyhave given us, but what can that do withoutfood?. . .. In the camp here as you move around,you will find children moving aimlessly, theypick up anything and eat it, even when it isdirty, they pick it up an eat it. When they finda little food thrown somewhere, they fight overit and you will find them crying. Also, thereare children here who are not strong againsthunger, you will get them crying the whole day.The mother comes back in the evening, cooksat night and the child will eat now while sleepyand that is why many children’s bodies are justswelling, it is painful to see the suffering childrenhere. —Traditional birth attendant FGD, Pabocamp.

There were frequent reports of children being contin-uously ill with conditions such as malaria, diarrhoea, skinrash, cough. For example, a child in one of the familycase studies was ill 11 of the 15 times we visited her andwas admitted to hospital four of those times. While not assevere, the same cycle of illness played out in the other fivecase studies. Furthermore, all reported times when povertystopped them from being able to seek medical care, eitherthey could not afford drugs, the cost of transport to thehospital, or the work time that would be lost if children wereadmitted. Food was the frequently unattainable priority forimpoverished caregivers and meeting other needs had to beprioritized by survival ranking.

. . . Most people still do not have money in theirhands, that is why you find children withoutclothes on their body. . .. Most of the people inthe community, their worry right now is to lookfor food. . .. Other things do not matter. Theywill not mind whether a child has clothing or issick . . .. the majority cannot send their childrento school, their priority is first food becauseyou as a parent, food is always first for yourfamily, food is the first necessity in a family, no

one can do anything without food and mostfamilies only have the strength to look for foodbut not any other thing, they are interested (inpromoting children’s development) but are justdefeated because they do not have any meansof survival. —FGD with the Child ProtectionCommittee, while the group was held in a camp,most had returned to home villages.

3.2.4. Hard Work, Poverty Reduction Approaches, and Persis-tence for a Better Future. People spoke of working long hardhours to rebuild, provide, and bring their children home.This hard work contributed to familial resilience and whenthe drought passed, some participants recounted how theircrops began to yield adequately if not abundantly. Childrenof families who had been settled for longer periods wereobserved to be healthier and had more appropriate weight-for-age.

Those who did not have land and social support spokeof long gruelling hours doing casual agricultural labourfor cash or food, gathering wild vegetables from the bush,and/or doing small-scale trading for their children’s survival.Participants accounts suggest they valued a strong work ethicas the way to get proper food, meet basic needs, and sendchildren for education for a better future.

Now that we have come back to the village,the people are really struggling [working withall their strength] to take care of the children.So their life is really on cultivation, seriouscultivation [of their land] and this struggle isaimed at helping so that the children can havethe strength in their bodies. So we are actuallystruggling now that we have come back to thevillage, on our own land. We want to obtainenough food so that we can get money, thenwe get other things that can help us put clotheson their bodies and even send them to schoolto protect the children and this struggle is at avery high degree; it is not decreasing either. —49-year-old traditional birth attendant, widowedand caring for 6 children.

The data also revealed a range of additional techniquescaregivers used to combat food insecurity, poverty and lack:working communally in groups and rotating through eachmember’s land; exchanging food to gain greater variety;selling harvest to meet other needs; participating in groupsavings and loans schemes (a skill learned while living incamps). All of these strategies rendered caregivers better ableto feed and provide for their children.

3.3. Social (Care-Giving) Environment of Children afterConflict. This section presents themes that illustrate thesocial environment in which young children lived duringtransition. The major subthemes are (1) survival-basedneglect of children, (2) the vulnerability of children withoutparental care, (3) the social protection of villages.


3.3.1. Survival-Based Neglect. When caregivers had to workdaily to meet basic survival needs, preambulatory breastfedbabies were generally taken along to the agricultural landwhere they would remain on the backs of their mothers or beplaced in the shade, sometimes with an older child who wasbrought along to provide care. However, many participantsreported that once children were walking they could not bebrought along and would be left in the camps. As one AmuruGovernment official noted “mothers are feeling conflictedbecause they have to go and work in the fields and if the childis a little bit older, they cannot take them.”

For families based in camps or resettling in villages closeto camps, caregivers could commute to the casual laboursite or village lands daily for work, returning in the evening.Families whose villages were far away could not move backand forth daily and left camps for extended periods of time,some reporting weeks or even months. This meant having notime to teach, interact with, or monitor their children. Whileparticipants expressed the vulnerability of this situationmany talked of having no alternatives. Early resettlementwas lamented as being a very difficult time for children whowere exposed to a myriad of factors acknowledged to hinderhealth, development, and well-being.

. . . Because of this poverty the child cannot getenough food, nor enough clothes, nor enoughteaching because the parent goes about lookingfor avenues to earn a living; there is now no timefor guiding the child. —28-year-old male LocalCouncil Leader in return to village.

Participants revealed a hierarchy of preferred careoptions for young children who had to be left behind; asupervising adult such as a grandparent or neighbour as afirst preference, followed by an older child in charge, andlastly, children left amongst their peer groups. Sadly, reportssuggested that many of the elders who would traditionallyhave provided supervision while parents were out cultivatinghad either died during war or were themselves forced to goout and work for survival. Additionally, many examples wereobserved of grandparents who had once again assumed therole of primary caregivers because parents had died, beenabducted, or left their children.

. . . In the past we spent a lot of time withour grandchildren, but now, you cannot spendmuch time with them because you have to lookfor means of survival. These days we the dayo(grandmothers), we go to the garden becausewe lost our sons who would have gone to dothe work we are doing now and the gardens arefar; you go in the morning, leaving when all youhave done is sweep the compound and you justleave water for the child to use to wash his orher face. You go away and come back in theevening now to begin preparing food for them.Your grandchild may spend lunch without foodbut in the past, we could feed them at least twoto three times in a day. We now do not have timeto bathe our grandchildren. We do not have time

to tell them stories. The time you are supposedto be telling them stories, you may be too tiredto even talk. So, I see that our role has changedjust because we are not spending much timewith our grandchildren, we do not have time toteach them, we do not have time to cook foodfor them, we do not have time to play with thembecause we get involved in other work like casuallabour, petty trade, and digging in the garden.FGD with elder women.

3.3.2. The Vulnerability of Children without Parental Care andProvisions. In Acholi culture, children had always assumeda care-giving and stimulation role for other children, sochild-to-child caretaking during resettlement was not new.It was a time-proven practice that served to meet many ofthe stimulation and care needs of children within the foldsof the extended family. However, what was acknowledgedto make transition a uniquely vulnerable period was thatchildren were frequently reported to be without adults inthe vicinity to supervise and assist the child caretakers. Inone remote camp, the team observed dozens of childrenof all ages without supervising adults. Additionally, peoplespoke of children being left without food or money to sustainthemselves while parents were away working. The followingexcerpt from FDG with siblings who remained in a campillustrates some of the serious issues faced by children whenparents were gone to the village for prolonged periods.

Participant 2. There is always no one; theyalways go away all to the garden and you findvery few adults within the camp and I may notbe knowing them and cannot go to them forhelp even when something happens; even whena child is sick. . . . . . Night hours are a nightmareto us.

Participant 3. We suffer at night. They (adultintruders) carry away our food and we hearthem saying “your mother is not around, yourmother has gone to the village.”

Participants 1. They always see and notice thatour parents have left for the village.

Participants 4. They may even know you andyour parents.

Participants 2. At times we do not know thepeople who come to steal; we wake up in themorning not knowing who has taken our food,but at times we know the people. FGD with 4half-siblings between the ages of 9 and 13 living incamp with younger siblings while parents returnto the village to work and rebuild.

A situation of even greater vulnerability occurred whenyoung children were left amongst their peer groups (i.e.,groups of children 5 years and below). This would happenif older children were in school and therefore unavailable


for care or if there were no older children or supervisingadults available in the family. This practice was observed inall camps and was noted by all categories of participants.

An informal interview with an employee of UNICEFindicated that “children deprived of parental care” was amajor issue experienced during transition. The Child Protec-tion Committee reports indicated that this issue composed23% of reported cases in 2009. The following excerpt is froman FGD with the Child Protection Committee members:

Participant 4. Ah what I have seen happeninghere these days which is very bad in Pabo here,most people returning home, they leave childrenbehind without food and you find the childrenmoving aimlessly in the camp, they move nearrestaurants, you find them picking up discardedfood and discarded millet bread, the ones whichpeople have eaten and left. . ..

Participant 6. Just yesterday I saw some twoparents leaving their young children behind,children of 1 year and 2 years and even 3 years,they leave them home for the whole day, theygo to their gardens for long hours, come backlate in the evening and you will find the childrenhungry the whole day or not even breast fed. . ..

Participant 1. There are those who do not havelapidi (child babysitter). You see, for us hereonce a child lacks a lapidi that child will alwayssuffer the moment the parents leave for thegarden. Such a child will try to survive on his orher own and will not know how to differentiatethat this thing is good or bad.

As the previous quote illustrates, when young childrenwere left without adult supervision and provisions, partic-ipants reported a number of very serious outcomes. Thefollowing outcomes which appeared in transcripts are listedin order of frequency of mention: hunger (and subsequentmalnutrition); falling seriously ill or being injured (falls,burns, bites, beatings) with nobody to help; suffering anddistress experienced without comfort provided; missing outon teaching, guidance; picking up bad behaviours such asstealing, fighting; wandering around or loitering aimlesslyand unengaged; and being subject to predation by others incamp, such as coercion, rape, theft. Acholi caregivers placedgreat value in their children and as many of the quoteshave demonstrated, there were high levels of knowledgeregarding risks and outcomes if children’s needs were notmet as well as the factors that would offer protection fortheir children’s futures. Yet the circumstances in postconflicttransition rendered many unable to change their children’senvironments and experiences.

. . . With children if they miss all that we havebeen telling you of (their needs), in futurenothing will come out of them. There is nothingthat they will do that will be progressive. Ifwe cannot help our children now, and we say

that we shall help them maybe in two yearsfrom now, we shall be wasting our resourcesbecause they will not be much of a help tous. . .. Our children will not be able to study, weshall not have a good generation. If we begintaking care of our children well now and wethen take them to school, they will completetheir education well, they will be able to supportus and even support other great grandchildren.But right now we have spoiled what would havebeen good for the future of our children. Ourchildren will grow up to be people who alwayscommit crimes. Our children, because they arenot getting enough food and sicknesses disturbthem a lot, in the future, we shall have childrenwho all have mental problems. —Traditionalbirth attendant FGD participant, Pabo camp.

3.3.3. Social Protection Offered by the Village. When familiesresettled fully in their villages with their children, they beganto report lessening degrees of vulnerability. In villages, evenwhen parents were working in the gardens, they or anotheradult was generally within earshot and could hear children’scries or children could go to the adults if needed. Homesteadswere spaced far apart with only vast expanses of agriculturalland and bush in between so children would remain near thehome where they generally had access to food, water, shade,and wide open, controlled spaces for play.

I have realized some changes at least in comingback home in the life of my children becausethe condition in which they were when in thecamp was not good. The camp used to be sooppressive they could hardly play well. Therewas no particular playground or play space thatthey could find in the camp, they were not free.But now that they have come back to the village,they play anywhere and they are very free, theyrun over to the other tree, then come back tothe other side and at least they have rested. Theyare even quite free (the wind is blowing aroundthem). Even me, as a mother, I am feeling sofree. I do not have to keep on controlling mychild so closely, protecting my child “oh, I haveto protect my child from so and so, or perhapsmy child might do something bad in some placeor to someone’s property who is not around”. —Case study: 27 y.o. married woman, caring for 7children. Recently transferred to the village from anearby camp.

The data showed a positive trend in social-cultural sup-port restoring across time when families resettled successfullyin the village. After so long in camps where parents spokeof having very little control for ensuring positive nurturingenvironments for their children, return was a most welcomerestoration of the highly valued social cultural ways of thepast. This included restoration of practices such as thenightly wangoo, or family campfire, where family would


come to unite, plan out how to meet needs, share songs andstories, and teach children.

3.4. The Regional Resource and Service Environment ofChildren after Conflict. This section will illustrate themesrelating to the regional resource environment of postcon-flict transition as it relates to young children. The majorsubthemes are (1) lack of services in return sites and (2)problems with targeting and implementation of services.

3.4.1. Lack of Services in Return Sites. As was coveredabove, participant reports suggested that the majority ofservices provided to children during war and displacementby nongovernmental and international organizations ceasedto operate or were scaled down significantly when war endedand resettlement began.

. . . Now, when people are returning to theiroriginal homes, there should be programs whichshould be targeting them when they are goingback to their original sites, but at the momentthey are not, there are no programs which areactually targeting people who are returning totheir original sites, most especially when youtalk about the children. . . —Government official,Amuru District.

While participant observation revealed that there were arange of interventions operated by development partners andgovernment during the postconflict period such as agricul-tural support/training programs, assistance with repatriationand/or food aid for “extremely vulnerable individuals”(people with disabilities, the elderly, persons who are HIVpositive), hospital-based nutritional supplementation forchildren who attended with serious undernutrition (whensupplements were available), and building of infrastructuresuch as health centres and schools, many of these serviceswere insufficient in scale or too centralized in location tomeet the needs of the dispersing population. Furthermore,while many programs benefited children indirectly throughbolstering the family unit, few programs targeted youngchildren directly. For instance, in the Pabo camp someparticipants recalled approximately 5 early childhood centresthat had existed during war; however, all but two had beenabandoned and fallen into disrepair during the postconflicttransition—a time when they would have been highlybeneficial. The two that were confirmed to be in existenceeither charged high fees that were unattainable to most ortargeted specific populations such as children with disability.

As one employee of an international NGO reported, therewas a significant funding gap after conflict, the conflict-oriented funding had been withdrawn, and developmentfunding was insufficient to replace it. This was a point ofresentment and frustration clearly for leaders and devel-opment workers, but even more so for many caregiverparticipants. Upon return to villages (particularly remotevillages), they lost or had substantively reduced access toservices and infrastructure for their children. These wereservices that had come to be highly valued during camp

living like health care, clean water, and education. Somevillages reported a lack of markets that made it difficult toaccess needed staples like soap, salt, sugar, and to sell foodsthat they had grown in order to get resources to supportchildren.

. . . The lack of school and then also missinga big therapeutic/supplementary feeding centreto encourage the brain and thinking of ourchildren. So ignorance is going to be the resultin the lives of our children. . .. Because there is nohospital, most of our children will now not live.The result will now be many graves filling up thewhole place. People say that there is change withthe dawning of the day, but it looks like with us,the dawning of the day only brings us problemsevery day. —30-year-old rwot kweri (traditionalchief) returned to village.

. . . What is causing life to be difficult now thatpeople are returning and the war is ended is thatwhere people are returning to there is no properwater, no hospital, no schools. . .. That meansit is not easy to keep good health among thepeople. —25-year-old father of three, husbandto two women, living in small transition camp;ancestral land is far away and is under dispute.

3.4.2. Problems with Targeting and Implementation of Services.Services that were being offered for children were notedby some to be a poor match for the most pressing needs.For example, nutritional education being provided duringdrought when children did not have food to eat; or healthcentres open only during daytime hours. Some servicesdesigned to reach children at the village level such as thevillage health teams (VHTs) who were to monitor, providehealth education, and dispense basic drugs such as malariatreatment, were spoken of as having started out strong,but then faltered in effectiveness due to a lack of resourcessuch as drugs and support, compensation of workers, andmonitoring.

. . . It (VHT) has reduced the strength andlevel of sicknesses that disturb children—ithad actually gone down—but beginning fromthe end of the past year when the medicineswere finished, that is when sicknesses began todisturb children again so much. Also in thisplace the death rate has been going higher. —25-year-old male village health team member andRwot Kweri (traditional chief).

This pattern of faltering services was reported repeatedlyby community leaders, both government and frontlineworkers. They spoke of the deficiency of monitoring, lackof sustained support, and limitations to the evaluation ofimplemented programs. While organizations were strong oninitiating, participants felt follow-through was often poorand they were neglected in communities as the program


that had offered so much promise for their children peteredout. This leads to expressions of both disappointment anda consequent lack of trust in the promises made for theirchildren.

. . .When these (early childhood care) centres arestarted by these development partners, peoplehave very high expectations. So people startedsending their children to these centres becausethe caregivers have been promised they will payjust a certain amount of shillings. But now whenconflict ended people (implementers) began justto desert the centres . . . and that is why you seethem dying out because the NGO started themand when their contract expires, we have nosupport for that centre. Amuru District official.

Some participants recounted maintaining their homes inthe camps for longer periods or leaving their children behindbecause of proximity to services such as schools and healthcentres which were not available in return sites.

The one program consistently reported to reach children,even those in distant rural locales, was immunizationservices. Immunizations were provided through the coop-eration of government agencies, international organizationssuch as UNICEF and NGOs on an outreach basis. Commu-nity leaders would mobilize their people to gather on theexpected dates to receive services and reports suggested highlevels of satisfaction.

4. Discussion

In the aftermath of a vicious 20-year war in northernUganda, caregivers and communities struggled to rebuildtheir lives and ensure their children’s survival. In the recoveryfrom more than a decade of displacement, the majorresource available to facilitate their transition home washard, prolonged labour to restore agricultural lands, rebuildresources and homesteads. Caregivers engaged in this workand strove to get their children out of camps so they couldreturn to traditional childrearing practices. They longedfor times when resources such as food and livestock wereavailable, the places where children lived and played werecontrolled, and the family surrounded and nurtured youngchildren. But through the difficult process of transition, thereality they reported was that the environments of earlychildhood were not supportive, safe, or nurturing.

The aftermath of war brought continued vulnerability tothe youngest members of society whose rapidly developingbrains and bodies were laying down the foundations of theirfuture well-being. Young children experienced numerousrisks to their health and development, risks that previ-ous research has documented as threatening to long-termdevelopmental outcomes [6, 12, 40]. These risks includedmalnutrition, poor health, and survival-based neglect in theform of reduced care, supervision, teaching, and stimulation.As risks accumulated, so did the threat to cognitive, social-emotional, and/or physical well-being; yet, as noted byWessels and Edgerton [41], accumulation is typical of too

many children both during and after war [42]. Furthermore,while caregivers and community leaders showed high levelsof awareness about the risks to young children, their poverty,lost social support, and necessary focus on survival oftenprevented mitigation. Support and assistance was also notforthcoming from external sources. The findings of thisstudy suggested that, when emergency focused interventionswere withdrawn after conflict, services remained largelycentralized and were not scaled sufficiently to address theneeds of young children. Furthermore, some interventionsthat did exist were felt to be poorly targeted or lackedmonitoring, evaluation, and sustainability.

There are approximately 26 million internally displacedpeople globally, people who remain within their owncountries but who are forced to leave their homes dueto conflict, violations of human rights, and/or generalizedviolence [41]. The African continent is the most impactedby internal displacement with an estimated 11.6 millionpeople affected, approximately half of whom are children[41]. These children are away from their home environmentsand social supports that provide routine and nurture duringthe most critical stages of their development. Moreover, asthe narratives of Acholi caregivers in northern Uganda bringto light, when the emergency phase concludes, the vulnera-bilities faced by young children can persist, particularly whendisplacement has been prolonged. There is vast and growingevidence documenting the critical importance of the earlyyears, which has led to policy and interventions that strive tomitigate risks to children and meet the unique needs of earlychildhood. International bodies such as the United Nations,the World Bank, and the World Health Organization havecalled upon governments to increase attention, training,and spending for early childhood development (ECD) inorder to create holistic, accessible, and culturally appropriateprograms that involve families and communities and arebased on partnerships [43]. Unlike that in the past, ECDnow has a significant presence in international policy withcharters and declarations such as the World Declaration forEducation for All (UNESCO, 1990), the Convention on theRights of the Child (UN, 1989), The African Charter on theRights and Welfare of Children ACRWC (1990) [44], and theOrganization for African Unity’s: “Africa Common Position:Africa Fit for Children” [45]. Today ECD is also includedin two of the major global targets for development—theMillennium Development Goals (MDGs) and Educationfor All (EFA) [46]. Nonetheless, the calls for action areinsufficient if they cannot or do not address those difficultto reach, the children who are exposed to the most difficultenvironments, and the greatest levels of risk such as thosehighlighted in this research and supported by others in thefield [16–19].

As the report on early childhood from the WorldHealth Organization’s Commission on Social Determinantssuggests, families need support and sustained commitmentfrom regional, national, and international communities toprovide nurturing environments for children and preservetheir developmental potential [2]. Yet participants in thisstudy indicated that there is a continued need to strive todevelop and/or effectively implement policies and practice


guidelines for government, international organizations, andnongovernmental organizations that focus on protectingyoung children and supporting their healthy development inwar and displacement. Such initiatives should include obli-gations of continued context appropriate support beyond theperiod of conflict in recognition of dependency, expectation,and need created within the population. While the challengesof providing such support are numerous [42], the potentiallong-term risks of not doing so, for both child and society,are too great to forego.

In northern Uganda, risks to young children in postcon-flict resettlement could have been mitigated to a much higherlevel. Nonetheless, the experiences of these children shouldinform better approaches in the future. Targeting is requiredat both the macro- and microlevels to rebuild communitiesand environments that support and enable children anddirectly meet the needs of individual children [42]. Forinstance, while policies exist to address the separationof children from caregivers in war zones, this does notacknowledge the separation that occurs when caregiversmust choose to leave children for the sake of rebuildinglivelihood following conflict. Yet, the outcomes for youngchildren in these situations can be the same—long periodsof time without the protection, care, and attention of aprimary caregiver and exposure to a myriad of risks fromthe social and physical environments. Findings of this studysuggest a need for increased efforts to implement culturallyappropriate childcare solutions following conflict led by theideas and practices of local people to facilitate the well-being of children throughout the transition process. Potentialsolutions may be found in the poverty-reduction strategiesalready being employed at the grassroots village level suchas in cooperatives of rotating caregivers, the trade of goods,and/or labour for childcare services.

Another example of an area of need, which the partic-ipants of this study reported to be inadequately addressedwas nutritional vulnerability during postconflict transition.While there were categories of “extremely vulnerable individ-uals” (EVIs) targeted for extra food aid in northern Uganda,reports and observation suggested that young childrenwere not amongst them. Acknowledging that continueddependence on food aid is not a desirable outcome of pro-gramming during resettlement, it also must be acknowledgedthat young children’s brains and bodies are particularlyvulnerable to nutritional deprivation and that long-termoutcomes can be serious [12, 40]. Targeting young childrenand breast-feeding and pregnant mothers as categories of“EVI” deserves further consideration.

On a more macrolevel, findings suggested a need toproactively implement innovative ways of reaching dis-persing paediatric populations in postconflict resettlement.Participants indicated a need for services such as accessiblehealthcare, clean water, and early childhood educationinterventions. Grassroots research is required to guide theplanning and monitoring of such services so the realitiesand most pressing needs of those who are dispersed andhard to reach drive the solutions. When commitments aremade and services are implemented that reach communities,greater attention and action is required to sustain programs

and/or find realistic solutions for transferring them to localgovernment or communities. The participants of this studyexpressed great frustration and disappointment over havingprograms introduced only to see them fail shortly thereafterdue to a lack of monitoring and ongoing support. Moneyinvested in services that fail, or which reach only limited, cen-tralized populations and miss those with the greatest need,could be better directed. In northern Uganda, services suchas immunization outreach were reporting success, yet suchremote outreaches were perhaps underutilized as a meansof providing additional services that address health needs.Interventions such as the Child Protection Committees orvillage health teams working at the community level offeredtremendous promise in meeting young children’s needs—members were highly knowledgeable about the risks beingfaced by young children within their communities. However,if no follow-up support is given to address the risk identifiedby these teams, frustration ensues, work diminishes andchildren lose this resource. Implementers need monitoringand evaluation research that gathers evidence as to whetheror not interventions are succeeding, as well as why or whynot.

This exploratory study shed light on factors threateningthe developmental potential of young children in postconflictnorthern Uganda. It offers a starting point on which furtherstudy could be based; however, some limitations are noted. Itdid not include all districts in the north nor urban dwellers;the extent to which these people face similar issues isunknown. While case study methodology offered some lon-gitudinal perspective, much of the data was cross-sectional,capturing a moment in time. Long-term followup wouldoffer greater perspective on outcomes for children. Tworesearchers conducted participant observations, and theirpositioning will differ from other researchers. Nonetheless,their audit trail and debriefing with other research teammembers offers some assurance of rigor in the analysis andinterpretation of findings. There may have been recall bias inthe retrospective accounts, or participants may have soughtto tell the researchers what they wanted to hear or presenta situation to elicit service delivery. However, relatively largesample of participants, range of data sources, and volume ofdata help to mediate any systematic respondent bias.

5. Conclusions

War and displacement have profound impacts on youngchildren and their families. Families who are rebuildingtheir livelihoods after such devastation need support tomove beyond a survival focus and to recreate nurturingenvironments for their children. Regional, national, andinternational bodies have acknowledged the critical impor-tance of early childhood and laid the policy and resourcefoundations to meet needs, but, as is shown in this study,more must be done to tangibly assist those living in themost difficult environments who are the hardest to reachand the most vulnerable. Failure to do so jeopardizes thefuture of a healthy prosperous society. Societies impactedby war desperately need to preserve the human capital that


will ensure that the future is better than their past. As the2011 World Development Report on Conflict, Security andDevelopment [47] states:

No low-income fragile or conflict-affectedcountry has yet achieved a single MDG (Mil-lennium Development Goal). People in fragileand conflict-affected states are more than twiceas likely to be undernourished as those in otherdeveloping countries, more than three timesas likely to be unable to send their childrento school, twice as likely to see their childrendie before age five, and more than twice aslikely to lack clean water. On average, a countrythat experienced major violence over the periodfrom 1981 to 2005 has a poverty rate 21percentage points higher than a country that sawno violence. . . (p. 5).

Health, peace, and development cannot exist without ahealthy thriving human population, and a thriving humanpopulation cannot exist without healthy, peaceful, thrivingchildren.

Acknowledgments

In deepest gratitude the authors acknowledge the partici-pants of the study who took time from their life sustainingwork to be a part of this research for the sake of children.They thank the experts at the Makerere Child Health andDevelopment Centre for their guidance, particularly HerbertMuyinda. They are grateful to the skilled and dedicatedpeople who provided daily support to this work: Ketty AkelloOtim, Samuel Lakor, Martin Ochieng, and David Ojok. Theyacknowledge with appreciation the Centre for InternationalChild Health at BC Children’s Hospital, the Child and FamilyResearch Institute, the International Development ResearchCentre, and The Human Early Learning Partnership at theUniversity of British Columbia for the funding to conductthis research.

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